The Cheetah Trial

CHEETAH – Cluster randomised trial of sterile glove and instrument change at the time of wound closure to reduce surgical site infection. A trial in low and middle income countries (LMICs)

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Patients recruited

CHEETAH is an international, multicentre, 2-arm, cluster randomised controlled trial with an internal pilot to evaluate the use of separate sterile gloves and instruments for wound closure to reduce SSI rates in patients undergoing surgery with an abdominal incision. Clusters are defined as hospitals.
CHEETAH is after FALCON the second global surgical trial from the NIHR-GSU network.

Aims & Objectives

  • Primary Objective

    The primary objective of the CHEETAH RCT is to assess whether the practice of using separate, sterile gloves and instruments to close wounds at the end of surgery can reduce surgical site infection at 30-days post-surgery for patients undergoing clean-contaminated, contaminated or dirty abdominal surgery, compared to current routine hospital practice.

  • Secondary Objective

    The secondary objective of the CHEETAH RCT is to assess the impact of changing gloves/instruments prior to wound closure compared to current routine hospital practice on secondary clinical outcomes up to 30 days post-surgery including: SSI during the in-hospital stay, re-admission, re-operation, length of hospital stay, return to normal activities, and death.

  • The recruitment target is a total of 12,800 participants from 64 clusters (hospital), each including up to 200 participants.

Collaborating countries

CHEETAH is an international trial being conducted in multiple NIHR funded countries. Click on the map below to see participating countries.

Trial summary

Surgical site infection (SSI) represents a major burden for patients, doctors and health systems around the world, but is potentially preventable. SSI is the most common postoperative complication across all income and development settings, and the most common healthcare-associated infection in low-and middle-income countries (LMICs). It has been associated with one-third of postoperative deaths and accounts for 8% of all deaths caused by a nosocomial infection. Rates vary significantly between different types of surgery, but it is particularly prevalent in abdominal operations; as many as one in four patients get an SSI when the operation involves the bowel.

Improving surgical outcomes is a global health priority, highlighted by the Lancet Commission on Global Surgery. Recent WHO guidelines made 29 recommendations for intraoperative and postoperative measures to prevent SSI. Despite inclusion of strongly graded recommendations, there was little high-quality evidence in support of most interventions. In addition, none of the evidence used was derived from resource limited settings, leading to uncertainty about implementation of measures in LMICs, in particular. The specific interventions to be tested in this study were selected by a Delphi process from a long list of potential interventions based on the the WHO guidelines.

A key factor influencing SSI rates is intraoperative contamination (opening the gut, genital or urinary tracts). In clean (non-contaminated) surgery, the infection rate is low and benefits from research targeting SSI rates in those patients are limited. CHEETAH will therefore focus on clean-contaminated, contaminated and dirty surgery. A cluster randomised design is considered the most appropriate design to minimise the risk of contamination in the control arm of the trial. Once theatre staff have been trained to implement the intervention (of separating sterile surgical instruments and gloves at the time of wound closure) it is likely to become routine practice, making individual randomisation unfeasible.

To assess whether the practice of using separate sterile gloves and instruments to close wounds at the end of surgery compared to current routine hospital practice can reduce surgical site infection at 30-days post-surgery for patients undergoing clean-contaminated, contaminated or dirty abdominal surgery.

CHEETAH is an international, multicentre, 2-arm, cluster randomised controlled trial, with an internal pilot. Clusters are defined as hospitals, which means hospitals rather than patients are randomised.

Patients (adults and children) undergoing emergency or elective abdominal surgery for a clean-contaminated, contaminated or dirty operation.

The intervention used within CHEETAH is:

  • Change of gloves and use of separate, sterile instruments before closing the abdominal wall

Comparator (current routine hospital practice):

No change of gloves or use of separate, sterile instruments before closing the abdominal wall